This PrEP-ed Life: Damon Jacobs on Sex and Dating in a New Era of HIV Prevention

Can you tell us about your PrEP regimen? How do you remember to take your pill, and when do you take it?

I have a pretty consistent routine, and I always have. Well, not always, but as long as I've been health conscious. I take vitamins. I'm not a health food nut; to be honest with you, I hate healthy food. I live off pizza. That's the thing. But, I take multivitamins. I take multivitamins that are rich with all these dried-up vegetables; they come from a special farm in Wisconsin. They're really good for you. So, that's really an important part for me, is to maintain a vitamin regimen and to eat breakfast every single day. Which is another thing we often do, all of us do, to neglect our self-care. It's so important. And I drink coffee. So, I wake up; I have my breakfast; I have my vitamins; I have my coffee. That was already an established routine in my adult life. Those are important things I do to take care of myself and start the day right. PrEP was just one thing to add into that. It wasn't anything that was inconvenient. It hasn't been something I've forgotten. It's just with the vitamins now. It's on the same little thing that the vitamins sit on, so I don't forget.

Did you feel that you had to go through a Truvada "coming-out process" where you had to tell people in your life that you were making a decision to go on PrEP? I mean friends and family, not sexual partners.

"If I'm dating someone who is positive, they will tell me that they're positive, and I will tell them about PrEP, and sometimes the response is 'Phew! Good!' And other times, the response will be, 'Well, we're still using condoms, because never in a million years would I knowingly put someone at risk for HIV. I just won't do that. That's not my principle.'"

Who likes to talk about anal sex with their friends and family? I mean, I kinda do, because that's the field I work in, and those of us who work in the HIV field often do anyway. Nevertheless, it's not always a common conversation that you have at the dinner table with your parents. And before it was approved, honestly, I was concerned about talking about it. I was concerned that my insurance would cease supporting this if I was open about it. The shift in me now telling my friends and family and trying to get the word out there is because the FDA did approve it. It's all on the record with the insurance companies.

So, yes, it was weird. I had to explain this to my parents before talking about this publicly, because I'm friends with my mom on Facebook, and I thought that, quite possibly, she's going to see some of my shenanigans. So, I explained to them, "If I was a woman and I told you I wanted to take birth control pills, would you support me?" And my parents were like, "Yeah, we'd support you on that." Then I said, "Well, if I told you that there was a pill that could actually prevent me from becoming HIV positive by almost 99 percent, would you support me on that?" And they said, "Why would you need that?" Ugh, not what you want to hear. So, basically, I explained to them the idea of oral prophylactics, of prevention, of responsibility, of prioritizing my mind, my body, my spirit. That's consistent with the work I've always done, both personally and professionally. And this was very much in alignment with that. That they got; that they understood.

The other thing with friends is just that people don't believe it -- because there's so little information out there, because this has not really been covered very much. So, the friends I told about this, they didn't disapprove, they were just scared. They didn't really believe that this works. They didn't think this was real. They just thought I was going out and being self-destructive. They don't think that now, but in the beginning when I was starting to talk about this, my friends were concerned that I was on this binge of self-destructive, hedonistic, bug-seeking anarchy. And didn't really understand. So again, I did my best to show them the research, show them the data that were out there. Explain to them that this was being done with a doctor. Time has shown that, OK, we're on the right path here. We know what we're doing.

How do you broach the subject of PrEP with potential sexual partners? Do you feel like you can say, "Oh, it's OK, I'm on a pill." Run us through that whole song and dance.

Well, as I said, dating in 2013 is really different from 2003, and one of the biggest differences is that the condom conversation doesn't happen half of the time. In San Francisco in the 1990s, there was no treatment, and half of the men in San Francisco were positive. So, it was pretty much a given that, if I was going to be sexually active, that 50 percent of the people I was going to meet were going to be positive. So I just assumed everyone was positive, regardless of what they told me, and acted accordingly. But there was often a conversation; there was some acknowledgement that a condom was being used.

A lot of guys don't use condoms and don't talk about condoms. Now, from an education, from a prevention standpoint, that's terrifying! But it's also for real. But to answer your question, it doesn't always come up. The conversation doesn't always happen.

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When I am with a partner, or if I'm dating someone who is positive, they will tell me that they're positive, and I will tell them about PrEP, and sometimes the response is "Phew! Good!" And other times, the response will be, "Well, we're still using condoms, because never in a million years would I knowingly put someone at risk for HIV. I just won't do that. That's not my principle." And that's a response I often get from the positive community. Here's what I say: "All right, cool, I understand. But here's what I also want you to consider. Daily use of PrEP has been shown consistently in different research studies to be 99 percent effective in preventing HIV. Daily use of antiretrovirals by someone who is positive has been shown to be about 96 percent effective in reducing the transmission of HIV. On my side, I've got 99 percent protection, on your side, you've got 96 percent protection. The likelihood that I will be getting HIV from you at this point in time is pretty miniscule."

But, to be political on another subject, when you look at the escalation of gun violence in this country, and you see that about 30 murders a day are happening in America in which people are being killed by guns, I feel like the likelihood of me getting shot right now is higher than the likelihood of me becoming HIV positive with those odds. So, I put it like that to partners and then I say, "So, what do you think?" Sometimes, they say, "Nope, I still will not have sex without condoms." And there are people who are like, "OK, I see where you're coming from. Let's get busy." And I respect people's right to use condoms. Which is one of the biggest misconceptions about people who take PrEP. We're not the anti-condom police.

They think that you're the "barebacking brigade"?

"We're talking about PrEP as one strategy to prevent HIV, not the strategy to prevent HIV. ... It has been an opportunity for people in serodiscordant relationships, including myself, to experience more intimacy and more pleasure than ever before in the 32 years of this thing called AIDS. And I, honestly, didn't know if I would ever see that in my lifetime."

Radical barebacking brigade! On the streets! We're talking about PrEP as one strategy to prevent HIV, not the strategy to prevent HIV. It is one strategy to prevent HIV. Along with condoms, along with positive people knowing that they're positive and taking antiretrovirals so that they cannot give HIV to another person. It has been an opportunity for people in serodiscordant relationships, including myself, to experience more intimacy and more pleasure than ever before in the 32 years of this thing called AIDS. And I, honestly, didn't know if I would ever see that in my lifetime. I really didn't think I would ever see that in my lifetime, to be honest with you. It's really been a revelation in that way. So, to answer your question, sometimes I talk about it, sometimes I don't.

Does the condom conversation ever come up around STIs (sexually transmitted infections) other than HIV, since PrEP only protects against HIV? Or do people just not talk about it?

I'm telling you from my experience: People are not talking about HIV and they are definitely not talking about STIs. I'm not saying that's good. I'm not saying that's right. I'm not saying that's healthy. I'm just saying that's the reality of many hookups and of many of the conversations, or lack of conversations, out there.

This is why it is so so so important for people to have medical care with a doctor who they trust, who they respect. I always say, "If you can't talk to your doctor about getting fucked up the ass, then you have the wrong doctor!" You need to have a doctor who you trust. If you feel judged or criticized or condemned by your doctor because you have a healthy sex life or a sex drive, find a doctor who you trust. They are out there. In some areas they are easy to find, and in some areas they are not so easy to find.

You are a consumer. Not the patient. You are a consumer. That's a very different paradigm. Because a "patient" is passive, and just has to do what the doctor tells them do. A "consumer" can say, "If you don't treat me with a certain level of respect, and if you don't engage in a sophisticated, adult, respectful conversation with me about anal sex, then I, as a consumer, can go to somebody else who is willing and able to do that with me." That's the reason we have to have really positive relationships with the medical community, because part of taking PrEP is that it's so important to see your doctor consistently, have your blood drawn consistently, and get tested for other STIs, because PrEP does not offer ANY protection against syphilis, gonorrhea, herpes, all that fun stuff. There's no protection there. So, I do get my blood and urine drawn from my doctor every three months to screen for that.

Comment by: Craig Allen
(Raleigh, NC)
Sun., Sep. 8, 2013 at 11:23 am EDT
Just so you know, when you're talking HIV+ people who are in the habit of using condoms out of using them because you are one single case in which you have money and insurance and know PrEP is being taken correctly, does, in fact, make you part of the "bareback brigade" who is actively breaking down the habit of HIV+ men wearing condoms when they top.

Comment by: Joshua M.
(Culver City, CA)
Tue., Jul. 23, 2013 at 8:24 pm EDT
Congratulations Damon for not only discovering a 99% effective protection against contracting HIV while enjoying bareback sex, but also for managing to take advantage of a widely-viewed forum to convey this astounding message to those of us who are deeply and passionately condom haters! Your interview is just amazing, truly uplifting, and empowers those of us who have been unwilling to forfeit the profoundly passionate, incomparably sensitive and rapturously intimate joy of skin-on-skin intercourse to also take hope that we can now depend upon having the same degree of protection as those who shroud their manhood in a plastic burkha. The advice and information you present is welcome and valuable and as someone who rarely clicks to start a video interview I must admit that I actually expected another downer report intended to strike guilt and fear in those of us who, from years of fighting the battle, have become inured to those warnings.

One of the points you mentioned which particularly captured my attention was when you mentioned the subset of men in their 50s who think “…at this point in my life I’m going to die from something else, so why not, who cares about HIV.” I happen to be someone approaching that age and it had never entered my head that my 50s, or even my 60s, would be the time to throw in the towel. Who are these guys? It sounds like they’re suffering from Major Depression—which can also be alleviated by an oral medication.

Anyway, just let me say that it seems we’re finally reaching the point, as a community, where we can appreciate and respect one another whatever their personal choices may entail. I know I’ve been lucky depending on the word of my partners to protect me during raw sex (especially since I’m a bottom). Now though I won’t even need to “pop the question” but instead just “pop the pill.” Awesome!

Comment by: Damon L. Jacobs
(New York)
Mon., Aug. 5, 2013 at 5:29 pm EDTThank you Joshua! I appreciate your words. Although there is a pattern for some men in their 50s to give up condom use (without PrEP), I caution people from assuming it is a symptom of Major Depressive Disorder. We generally don't question the mental state of straight men who choose not use condoms. I'd say a lot of the times it simply "condom fatigue."

BTw - I'm from Culver City!

Thank you commenting... Damon

Comment by: Bob Skinner
(Corvallis Oregon)
Tue., Jul. 23, 2013 at 6:27 pm EDT
Bravo Damon, Thanks so much for reporting on this. As an HIV/AIDS educator I am frequently asked about this and how I feel about condom vs. a pill. At first I though it was just a way that the medical community was just using as a way to fill in the gaps of somewhat failed prevention messages. I know better now. As we now know PrEp can be very effective if taken correctly just like other ARV treatment. Thanks for getting me excited about this and keep up the good work !

Comment by: J. Silverstein
(Chicago)
Fri., Jul. 12, 2013 at 2:15 pm EDT
I find this article "very" interesting. However, I do have a couple wee comments...
Aids/HIV is obviously a global issue to us all on this planet(republicans) not included. Sorry, mate just a bit of tongue and cheek! Right, back to my point. Many of my straight mates are every bit as... free with love as "WE" are, therefore shouldn't this article focus on what the drug can and would do for both gay and straight individuals? Its simply daft to mention the "party" components of this drug when compared to its obvious life saving upside. People will abuse it or rather use it for other issues whether there is actual education about its proper use or not. Before, I get flamed by some clever sod let me address the 800lbs elephant in the room...Yes, if we all were 100% monogamous there wouldn't be as big of a need to adhere to this drugs proper use now would there? But, "WE" all are people with feelings and needs whether "gay or straight". Ignoring one's emotional/physical needs is just folly and not at all living in reality. If I was doing the PR for PreP I'd try to appeal to "ALL" people not just us brilliant gays. Aids/HIV after all doesn't give one single toss about who we humans fancy having a shag with--now does it? Loved your piece mate;-)! Cheers.

You are absolutely correct in asserting that PrEP education and information would ideally be targeted to EVERYONE who could be at risk. At the same time, 78% of new HIV infection rates in the U.S. are still occurring through M2M contacts. I would love to see women getting on board with this as a health issue.

Comment by: Damon L. Jacobs
(New York )
Mon., Jun. 3, 2013 at 4:17 pm EDTHi N. Van Der Bergh -- I have used both, depending on partner's preferences. Some people still prefer using condoms, and that is fine. Truvada is "A" strategy for prevention, not "THE" strategy. It is one of many tools, which includes condoms.

Comment by: Tom
(Orlando)
Wed., May. 29, 2013 at 5:06 pm EDT
Will you stop demonizing the AHF? The ONLY application for this pill is for recreational, and Weinstein deserves kudos for being the only person in the HIV community who said so and is still standing. PrEP is not going to stop the spread of HIV, it's not going to limit stigma, and it's sure as heck not going to make things better for anyone except the party crowd. The nonstop advertisement for a recreational drug on supposed educational sites has got to stop. It's a public health disaster waiting to happen, and everyone knows. Give it a rest, the entire world is rolling it's eyes.

I, for one, do not demonize the AHF. PrEP is not only used to enhance intimacy, but it is also being used as a prevention strategy by individuals in violent relationships who cannot (for various reasons) leave. It is also being used by sex workers to reduce safety risks. These groups may not be as public as I have, but one could reasonably say their use goes beyond "recreational."

PrEP is not going to stop the spread of HIV, but used effectively it could sure slow it down. We haven't seen any significant drops in new HIV infections in the U.S. for the past decade. PrEP could change that if it was widely known about and available.

In a sex negative paradigm, risk reduction and protection will always be a source of stigma and shame. Women have been dealing with this for decades in regard to having accessible birth control and abortion rights. We can all learn a lot about from Feminism about how to stand up for rights to express oneself sexually with a partner - even under the threat of misogyny and hate.

Comment by: Joel
(Houston, TX)
Tue., May. 28, 2013 at 10:21 pm EDT
Damon, thank you for telling your story. One of the saddest parts of this epidemic (besides the millions that have died and the fact that it didn't have to happen) is the cruelty and discrimination in our own community. As someone who is educated and who does not consider status when deciding who to date and who to love, I think the truth about this drug must finally be told. But it cannot be told without telling the story AHF and Michael Weinstein, who railed against the makers of Truvada and said that it would be a bareback festival, if approved. That did NOT happen, according to studies and the drug has proven very effective. Thanks again, Damon. Maybe our community can stop acting like Rick Santorum when it comes to people living with HIV/AIDS.

Comment by: WH
(Hartford, CT)
Sun., May. 26, 2013 at 6:42 pm EDT
What you don't mention is who is paying the expensive cost of this drug? I doubt any insurance coverage would cover something deemed "preventative" in this set of circumstances. By not disclosing that financial reality the article is incomplete.

Hiv+/Undetectable and 6 years strong on Truvada/Kaletra regimen. I know the issue of viral resistance - my initial diagnosis and viral analysis indicated I was one of the "lucky" that got the double whammy - diagnosis and the 25% that are infected with a resistant strain, most likely due to non-adherence by a patient on meds.

Comment by: prep taking in community
(anywhere?)
Wed., May. 29, 2013 at 11:27 am EDThi there, he talks on the first and second pps of the article about insurance companies. that looks like his insurance pays for it. my insurance pays as my doc prescribes as i am a person at risk.

Comment by: Damon L. Jacobs
(New York)
Sun., Jun. 2, 2013 at 12:05 am EDTHi WH - As of yet, no one that I know has been denied access to the drug through their insurance. In New York, the state Medicaid system now pays for it due to the efficacy. My understanding is that Medicaid is paying in other states, but not making a public pronouncement about it. Gilead has pledged to make it available through their Assistance Program for those with no means. One person I know has received it that way as well.

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